August 28, 2006

The Long-Term Outlook for Those with Dual Diagnosis is Hopeful

A summary review of "Ten-year recovery outcomes for clients with co-occurring schizophrenia and substance use disorders"

By Jennifer Barnett, Post-Doctoral Research Associate, University of Cambridge, Department of Psychiatry

Introduction to the study
Drug and alcohol abuse are very common among people who have schizophrenia. Regardless of whether or not drug use can cause schizophrenia, people with this serious brain disorder who take illegal drugs and/or abuse alcohol are more likely to have relapses, less likely to respond well to treatment, and more likely to require hospitalization than those who do not. The New Hampshire Dual Diagnosis Study has for the last ten years followed a group of people (N = 130) who met diagnostic criteria for schizophrenia and substance (drug and/or alcohol) abuse or dependence. This study reports on the outcomes of this group after ten years.

Who they followed
A group of 169 individuals with dual diagnoses of schizophrenia (or schizoaffective disorder) and substance abuse (use which causes legal, social, relationship or work problems or which puts user in dangerous situations) or dependence (physical or mental addiction) were enrolled into care management programs for 3 years (1989-1992). During the first 3 years, researchers met with the individuals (participants) every 6 months for structured interviews, urine toxicology screens (drug tests), and ratings of substance use/abuse. Then for the next 7 years, participants received usual treatment and were followed every year. Ten years after entering the programs, 130 of the original 169 participants remained in the study.

Participants in the study had a diagnosis of schizophrenia (70%) or schizoaffective disorder (30%) for an average of twelve years when they first entered the study, and a diagnosis of substance abuse/dependence for nearly 16 years. The majority of participants abused alcohol, around half abused cannabis and a small number abused other drugs, of which the most common was cocaine (14%). These were the drugs most common in New Hampshire at the time the study began.

What they found
Ten years later, the group of 130 subjects was doing surprisingly well. Psychiatric symptoms, especially those of thought disorder and mood, had significantly improved. However, cognitive disorganization symptoms had not improved.

Most people had also managed to cut down their drug or alcohol use; after ten years 65% were no longer abusing any substance and 39% had not used any for at least 6 months.

The greatest improvement in functioning was in the area of employment; at the beginning of the study only 6% of the group had been employed in the past year, whereas ten years later 41% were employed. Other social measures such as contact with friends who do not abuse drugs or alcohol also increased steadily over time.

Researchers consulted with several persons who were in recovery from dual diagnosis and came up with six aspects of recovery as follows:

1) Low levels of symptoms.
2) Managing to keep off drugs or alcohol
3) Living in your own house.
4) A job that pays at least minimum wage and is not part of a mental health recovery program.
5) Regular contact with friends who do not abuse drugs/alcohol.
6) General satisfaction with your quality of life.

As a group, improvement in all of these aspects over the ten year period was reported. Interestingly, the six aspects of recovery were only weakly related to one another. This means that there is not just one sort of recovery, different people recovered in different aspects of their life during this ten-year period. It should be noted that though the researchers carefully identified the 6 aspects of recovery, there were other factors considered important for recovery by the dual diagnosis advisors that were not directly measured, though what these factors were was not discussed.

What this means for schizophrenia
This study shows the outcomes for people with schizophrenia or schizoaffective disorder who were in a drug treatment program. The overall picture from this study is hopeful, and showed that most people (at least in New Hampshire) who have schizophrenia/schizoaffective disorder and substance use problems, and participate in a some sort of care management program, seem to steadily improve over the course of ten years. These improvements were seen both in terms of schizophrenia symptoms and in drug use, and were most apparent in independence, quality of life, and overall life satisfaction.

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